HFA Project #:______
¨ Initial Certification ¨ Recertification ¨ Other ______/ Move-In Date: ______
Effective Date: ______
Next Recert Date: ______
(YYYY-MM-DD)
PART I. DEVELOPMENT DATA
Property Name: County: BIN #: ______
Address: Unit #: # of Bedrooms: ______
PART II. HOUSEHOLD COMPOSITION
¨ Vacant Unit
HH Mbr # / Last Name / First Name / Middle Initial / Relation to Head of Household / Race / Ethnicity / Disabled (Yes/No) / Date of Birth / Full Time Student (Yes/No) / Last 4 Digits of SS#
1
2
3
4
5
6
7
PART III. GROSS ANNUAL INCOME
HH Mbr # / (A)
Employment or Wages / (B)
Social Security / Pensions / (C)
Public Assistance / (D)
Other Income
TOTALS
Add totals from above, (A) - (D), to determine total income. TOTAL INCOME (E) =
PART IV. INCOME FROM ASSETS
HH Mbr # / (F)
Type of Asset / (G)
C/I / (H)
Cash Value of Asset / (I)
Annual Income from Asset
Passbook / TOTALS
Enter Column (H) Total Rate
(If over $5,000) $______X 0.06% = $______(J) / IMPUTED INCOME (J) =
Enter the greater of: Total of column (I) or Imputed Income (J). TOTAL INCOME FROM ASSETS (K) =
Add (E) + (K) TOTAL ANNUAL HOUSEHOLD INCOME FROM ALL SOURCES (L) =
HOUSEHOLD CERTIFICATION & SIGNATURES
I/we have provided for each person(s) set forth in Part II acceptable verification of current anticipated annual income and assets. I/we agree to notify the landlord immediately if there are changes to the household composition or if any member becomes a full time student during the course of this tenancy. I/we will report any changes in income or household composition that occurs between the time this form is signed and the date it takes effect.
Under penalties of perjury, I/we certify that the information presented above is true and correct to the best of my/our knowledge and belief. I/we further understand that providing false representations (to include misleading or incomplete information) herein constitutes an act of fraud and may result in the termination of my/our lease.
Resident Signature Signature Date Resident Signature Signature Date
Resident Signature Signature Date Resident Signature Signature Date
Effective Date of Income Certification: ______Household Size at Certification: ______(YYYY-MM-DD)
PART V. DETERMINATION OF INCOME ELIGIBILITY
TOTAL ANNUAL HOUSEHOLD INCOME FROM ALL SOURCES:
From item (L) on page 1 / $ / RECERTIFICATION ONLY:
Household Income at Move-in: $______
Household Size at Move-in: ______
Current Income Limit x 140%: $______
(170% for Deep Rent Skewed Projects)
Household Income exceeds
140% (170%) at recertification: ¨ Yes ¨No
Current Income Limit
Per Family Size: $______
Household Meets Income Restriction at:
¨ 60% ¨ 50% ¨ 40% ¨ 30% ¨ ______%
PART VI. RENT
Tenant Paid Rent (TP) / $______/ Rent Assistance: $______
Utility Allowance (UA) / $______/ Other non-optional charges: $______
Identify other charges: ______
GROSS RENT FOR UNIT:
(TP + UA + Other non-optional charges) / $ /
Unit Meets Rent Restriction at:
Maximum Rent Limit for this unit: / $______/ ¨ 60% ¨ 50% ¨ 40% ¨ 30% ¨_____%
PART VII. STUDENT STATUS
ARE ALL OCCUPANTS FULL TIME STUDENTS? / *Student Exemptions:
1 TANF assistance
¨ Yes* ¨ No / If yes, enter student exemption* / 2 Job Training Program
3 Single parent/dependent child
4 Married/joint return
5 Previous Foster Care Assistance
PART VIII. PROGRAM TYPE
Mark the program(s) listed below (a. through e.) for which this household’s unit will be counted toward the property’s occupancy requirements. Under each program marked, indicate the household’s income status as established by this certification/recertification.
a. Tax Credit ¨
See Part V above. / b. HOME ¨
Income Status
¨ £ 50% AMGI
¨ £ 60% AMGI
¨ £ 80% AMGI
¨ OI** / c. Tax Exempt ¨
Income Status
¨ 50% AMGI¨ 60% AMGI
¨ 80% AMGI
¨ OI** / d. AHDP ¨
Income Status
¨ 50% AMGI
¨ 80% AMGI
¨ OI** / e. ¨
(Name of Program)
Income Status
¨ ______
¨ ______
¨ ______
¨ OI**
**Upon recertification, household was determined over-income (OI) according to eligibility requirements of the program(s) marked above.
SIGNATURE OF OWNER/REPRESENTATIVE
Based on the representations herein and upon the proof and documentation required to be submitted, the individual(s) named in Part II of this Tenant Income Certification is/are eligible under the provisions of Section 42 of the Internal Revenue Code, as amended, and the Land Use Restriction Agreement (if applicable), to live in an income/rent-restricted unit in this Project.
Printed Name of Owner/Representative Signature of Owner/Representative Signature Date
NYSHFA.1 LIHTC Program (revised by NYSHFA 1/10/11)
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